Treatment Strategy for Impending Instability in Spinal Metastases

Abstract

Backgroud Determining surgical management of a spinal metastasis is difficult owing to the involvement of multiple factors. The spinal instability neoplastic score (SINS) system is a reliable tool to evaluate instability in spinal metastases. The intermediate SINS (scores 7–12) indicates impending instability, which makes it difficult to determine the proper treatment strategy. In this study, we aimed to compare the initial status and treatment outcomes of a conservative group versus an operative group among patients with spinal metastases with an intermediate SINS of 7–12. Further, we evaluated the time for conversion to surgery in patients who had initially undergone conservative treatment and identified the factors associated with the conversion. Methods Among the patients with a spinal metastasis with an intermediate SINS of 7–12 from May 2013 to December 2017, those who were followed up for more than 12 months were enrolled in this study. Patients with signs of a neurologic deficit or cord compression at the initial diagnosis were excluded. Finally, 79 patients (47 in the initially conservative group and 32 in the initially operative group) were enrolled in this study. The performance status, Tomita score, and Tokuhashi score were assessed for group comparison. Components of SINS, the Bilsky grade, and radiosensitivity of tumor were evaluated to determine factors associated with conversion to surgery. Results Average follow-up was 20.9 months (range, 12–46 months). The demographic variables, primary cancer type, and performance status were not significantly different between the 2 groups. However, the Tomita score was lower in the initially operative group ( p = 0.006). The 1-year treatment outcome assessed based on the change in performance status and vertebral height collapse showed a tendency to deteriorate less in the initially operative group. The rate of conversion to surgery in the initially conservative group was 33% in the first year, after which there was little change in the incidence of conversion. When vertebral body collapse was less than 50% or the tumor was located in the semi-rigid region (T3–T10), the need for conversion to surgery increased statistically significantly ( p = 0.039 and p = 0.042, respectively). Conclusions The rate of conversion to surgery in initially conservatively treated patients was about 33% in the first year. When a tumor is located in T3–T10 and less than 50% vertebral body collapse is present, surgery may be the better choice than conservative treatment.

Management of Metastatic Spinal Cord Compression in Secondary Care: A Practice Reflection from Medway Maritime Hospital, Kent, UK

“…Among them, 29 (54.7%) had confirmed MSCC in MRI imaging (Figure 1). Impending MSCC, defined as a clinical entity without neurological deficits in the presence of epidural tumour touching the spinal cord, was diagnosed in 6 patients (11.3%) [9]. The most common malignancies within the confirmed MSCC subset were lung (11 patients, 37.9%), breast (5 patients, 17.2%), and renal (3 patients, 10.3%), followed by prostate, myeloma, and carcinoma of unknown primary (2 patients (6.9%) each), as well as pancreatic, colorectal, lymphoma, and bladder (1 patient (3.4%) each) ( Table 1).…”

“…Among them, 29 (54.7%) had confirmed MSCC in MRI imaging ( Figure 1 ). Impending MSCC, defined as a clinical entity without neurological deficits in the presence of epidural tumour touching the spinal cord, was diagnosed in 6 patients (11.3%) [ 9 ].…”

Correlation Between the Spinal Instability Neoplastic Score (SINS) and Patient Reported Outcomes

“…The following interpretation of correlation coefficients were applied according to rho <0.2: very weak, 0.20-0.39: weak, 0.40-0.59: moderate, 0.6-0.79: strong, and >0.8 very strong. 5 The Kruskal-Wallis test was applied to determine differences in PROs for the categories of the SINS mechanical pain factors at baseline and during follow-up. Furthermore, ad-hoc pairwise comparisons were performed for the single SINS mechanical pain categories adjusted by Dwass-Steel-Critchlow-Fligner for multiple comparisons.…”

Unstable Pathologic Vertebral Fractures in Multiple Myeloma : Propensity Score Matched Cohort Study between Reconstructive Surgery with Adjuvant Radiotherapy and Radiotherapy Alone

“…In this regard, local recurrence and nerve compression have been reported to be not easily controlled by RT alone 21) . Unstable spine due to PVFs might also be associated with long-term outcomes 15,24) . SINS in both groups suggested potentially unstable spine, and all patients in group I and matched cohorts in group II manifested potentially unstable or unstable lesions 11) .…”

“…Reconstructive surgical interventions are needed in a few cases with structural instability or neurologic compromises [ 8 , 15 , 33 ]. However, few studies have investigated the role of reconstructive surgery due to the rarity of disease [ 3 , 27 , 31 , 34 ].…”